North Carolina Health Insurance Articles & Resources

For all these reasons, pediatricians are frequently unaware of medications prescribed by MH providers and of therapeutic efforts important to the ongoing management of a child's emotional and family problems. An additional factor contributing to poor coordination is the paucity of care coordination programs in NC for children with behavioral problems and mental illness: the state-funded Child Services Coordination Program serves children with developmental and medical problems from birth to age 5; neither the Child Services Coordination Progam nor the state-supported Developmental Evaluation Centers serve school-aged children. Low ratios of school nurses in the state--1:2451 statewide, 1:5000 or more in some areas (3)--prevent most nurses from playing a role in coordination. Public school psychologists and guidance counselors, who deliver the majority of MH services to youth, (2) function virtually outside the health care system.

Compounding these reimbursement and coordination issues in NC, as elsewhere, are the problems arising from the compartmentalized training of MH and medical professionals and the separate administrative structures that perpetuate this compartmentalization. As a result, MH professionals and community pediatricians typically do not work in the same buildings, utilize the same terminology or diagnostic approach, attend the same educational programs, use the same forms or reimbursement codes, or sit at the same tables to address their concerns. At the level of state government, 2 separate systems, functioning largely in parallel and funded by separate streams, oversee medical programs in 1 building, MH programs in another. This separation posed significant challenges for the process of addressing NC's problems.

NC's ASSETS

NC has an active chapter of the American Academy of Pediatrics (AAP) and 5 academic pediatric programs whose chairs are closely involved in the chapter's educational and advocacy efforts. The chapter has a long history of effective collaboration with state government, enhanced by the tenure of David Bruton, MD, a community pediatrician from Pinehurst, North Carolina, who served as secretary of the Department of Health and Human Services from 1997-2001. The primary setting for the chapter's collaboration has been an open forum, convened 3 times yearly by the chapter, which brings together pediatricians, child advocates, and representatives of state government to update each other on important developments affecting the health of children and to address mutual concerns. The former Director of Medicaid, Richard Perruzzi, was among the attendees. Secretary Bruton and Mr Perruzzi worked closely with chapter leaders in developing a non-Medicaid State Children's Health Insurance Program (SCHIP) built around the State Health Plan (SHP) for state employees. The SHP experience in MH coverage had been especially positive: in 1992, NC introduced into the SHP full coverage parity of MH and non-MH conditions, a single insurance deductible, full freedom of choice of MH providers, and only moderate management of generous benefits through a contract with Value Behavioral Health. With MH parity in place, by 1998 NC had seen the following changes (4):

[??] MH payments as a percentage of total health payments decreased from % to %.

[??] MH hospital days decreased by 70%.

[??] Actual per member/per month cost for MH benefits (including administrative overhead) went from $ in fiscal year 1990 to $ in fiscal year 1998.

[??] Actual utilization patterns remained constant and modest: 6% to 7% of enrollees sought outpatient services per year; half went for only 3 to 4 sessions, three-fourths completed treatment within 11 to 13 sessions; utilization >26 visits remained constant and low (%%).

Although MH parity did not increase overall costs, and although it brought about a marked reduction in inpatient MH days (an outcome also documented by Sturm, who studied insurance plans that offered parity in behavioral health spending limits (5)), these data were insufficient to persuade state legislators to pass MH parity legislation on multiple annual attempts. However, the SHP experience was sufficient to open dialogue that could not have otherwise occurred in NC's fiscally conservative political climate.

THE PROCESS

1) Articulating Pediatricians' Perspective: The Position Paper

A critical first step was bringing together pediatricians to form a task force of NC's AAP chapter. Key members felt passionate about the MH issue, had expertise and experience, and were already involved in chapter leadership: a community pediatrician who chairs the chapter's Mental Health Committee and is the parent of a child with special developmental needs; an academic developmentalist from the chapter's Committee on Disabilities; a developmental pediatrician who serves as medical director of a community health program for low-income children in an urban county, former chair of the local Board of Mental Health, Developmental Disabilities, and Substance Abuse, and Chair of the chapter's School Health Committee; and an adolescent specialist in combined community and academic practice, former chair of the chapter's Committee on Adolescence. The chair of the group, which was named the Task Force on Mental Health Care Access and Reimbursement, is an academic generalist, formerly in private and public health settings, involved in developing school-based health services and serving as NC's AAP chapter president.

As the group began meeting to discuss the problem, anecdotal experiences and discussion about our sources of frustration dominated the discussion. It became evident that, to move forward, we needed to find expression for the angst, educate each other about unfamiliar aspects of the issues, and prepare to speak in one, understandable voice to fellow child advocates and policymakers. We settled on the idea of writing a position paper, which went through many iterations and served to focus our efforts during our first few months. This document appears on the Web site of the NC chapter of the AAP, which is available at: .org.

2) Including Other Stakeholders: Consensus Plan

Having reached consensus on the position paper, we began expanding our Task Force to include other MH advocates, including the executive directors of the state's organizations for social workers, psychologists, and psychiatrists and the president of the state's Council of Child and Adolescent Psychiatrists. These individuals brought with them their experience in lobbying the state legislature and state government on MH issues, linkage to other advocacy groups such as the Alliance for the Mentally Ill, and their own expressions of anger and frustration, which the Task Force processed and discussed over several meetings. With their input, the Task Force developed a plan of action, which served mutual goals; this plan became a second chapter of the position paper, which is available at: .org.

3) Working With Medicaid

With this document complete, we made the decision to approach Medicaid leadership. The group's optimism was greatly increased by a surprise legislative response to years of chapter advocacy, facilitated by Secretary Bruton, to increase Medicaid rates to parity with Medicare, effective January 1, 1999, and to allow clients 1 year of Medicaid eligibility, rather than month-to-month. Although these measures were not specific to MH and did not solve other problems, such as the absence of reimbursement for nonface-to-face activities and barriers to collaboration with Medicaid MH providers, they were enormously helpful to the cause and signaled a mood of receptiveness to physician concerns.

The Task Force approached the Director of Medicaid, and he agreed to meet with the group about its access and reimbursement concerns. We decided to locate the meeting in his conference room at the Division of Medical Assistance (DMA) building and have met there regularly since, frequently involving other members of the DMA staff and consulting with them about wording of new regulations resulting from our negotiations, as well as unrelated topics such as preventive dental programs, for which they needed our advice and support. We soon pulled in other members of state government, leaders from the Department of Mental Health, Developmental Disabilities and Substance Abuse Services, who had not previously interacted with our pediatric leadership, and began to address MH systems issues, as well as reimbursement. These new relationships continue to be of great value to the chapter.

4) Outcomes

Advocacy is not science; consequently, outcomes cannot be attributed tidily to any 1 factor in the complex environment of that period. Generations of chapter leaders gave this advocacy effort their legacy of credibility and effective relationships with state government. Secretary Bruton's powerful position and supportive posture toward the Task Force undoubtedly helped to get Medicaid leaders to the table and to facilitate progress. Other MH advocacy groups worked in parallel with the Task Force, invigorated by the support of pediatricians. To these ingredients the Task Force added focus, persistence, a consensus voice, a framework for negotiation, and access to the clinical expertise of pediatricians motivated to participate in a change effort.

Results came about laboriously. Several contentious issues required discussions by telephone or in small groups outside Task Force meetings. Occasionally, impacted groups (eg, physicians in local area MH programs) requested a hearing of their concerns, which were all heard first by Task Force representatives, then considered and addressed by the Task Force as a whole. Meticulous notes of meetings (an essential component of an advocacy effort) recorded agreements and reminded the group of unfinished business. Snags sometimes required data-gathering, outside expertise, and special visitors to Task Force meetings, occasionally including Secretary Bruton himself or other members of the Department of Health and Human Services staff. Periodically, the Task Force revised the position paper to clarify a point and then recirculated it to Secretary Bruton and other government leaders.

The following Medicaid changes resulted from this collaborative effort:

[check] Reimbursement for up to 6 visits to a MH/ substance abuse provider without assigning a diagnosis and up to 26 unmanaged visits in a calendar year for Medicaid recipients up to age 21. (6) DMA confirmed on October 12, 2001 that this policy also applies to physicians performing behavioral assessment and treatment.

[check] (a) Primary care provider referral for up to 26 MH visits annually for children under the age of 21. (7) MH providers are educated to communicate at regular intervals with the primary care provider.

[check] Expansion of "incident to" rules,[b] allowing physicians employing licensed clinical social workers, and clinical nurse specialists with psychiatric certification to bill for the services of these MH professionals if the physician provides on-site supervision. (8)

[check] Expansion of "incident to" rules, (b) allowing health departments who employ licensed clinical social workers, licensed psychologists, and advanced practice nurses to bill for their services in school-based health centers, if a physician provides supervision by phone or beeper. (9)

[check] (a) Direct Medicaid enrollment of independently practicing licensed clinical social workers, licensed psychologists, and advanced practice nurses allowing them to bill for services delivered in their offices. (10,11,12)

[check] An additional provision allowing independently enrolled MH professionals to bill for services delivered in school sites. (13)

We were not successful in achieving Medicaid reimbursement for nonface-to-face services. Nor were we successful in achieving an enhanced fee for services performed by pediatricians with subspecialty training. Both these approaches created troubling complications for DMA outside the realm of pediatrics. Although we were successful in enabling new categories of MH professionals to deliver services in school sites without on-site physician supervision, we were unsuccessful in expanding this opportunity to those employed by private physicians or universities.

We should add that some of these changes created new challenges for NC's area MH programs. For the first time, they must compete for physician referrals of low-income patients. A positive outcome has been their heightened interest in streamlining their own referral processes and enhancing communication with referring physicians. A negative outcome has been the growing phenomenon of split therapy, a name they have given to the circumstance that develops when a nonphysician community MH professional delivers a portion of a patient's therapy and a physician without an established relationship with that professional is expected to deliver the other (eg, emergency hospitalization or psychopharmacologic therapy). The latter problem appears amenable to relationship-building among the concerned parties and may prove an additional incentive to collaboration.

5) Educating Our Membership

To bring the membership of our chapter along in the process and to expand pediatricians' capacity to deliver and coordinate behavioral and MH services, we planned educational sessions around the topics our Task Force identified as most critical, including developmental and behavioral health screening, psychopharmacology, and coding for MH services and special needs health care. The session on coding received the highest evaluation of any offering. Future offerings will focus on expansion of other MH skills important to primary care pediatricians: use of the Diagnostic and Statistical Manual for Primary Care, family assessment, management of attention-deficit/ hyperactivity disorder and depression, collaboration with schools and other community agencies, referral to MH professionals, and behavioral therapy.

We met with the leadership of our NC area health education centers to plan regional grand rounds on MH topics. NC's Council of Child and Adolescent Psychiatrists is participating in this effort. The Northwest Area Health Education Center, which serves 17 counties, has undertaken a project to assist selected communities in organizing systems of care for children with attention problems. This effort will be patterned after a successful model in Guilford County, which developed a community protocol for the assessment of children with classroom inattention and behavior problems; established roles for school personnel, public health nurses, primary physicians, and MH agencies in the assessment and management of these children; created communication forms and procedures for each step of these processes; and implemented an educational plan for introducing these new procedures to physicians and school personnel.

The next phase of our educational effort will be workshops for pediatricians on collaboration with MH providers, explaining new reimbursement opportunities. We will be distributing the names of newly enrolled MH providers (>400 statewide as of this writing), information about their training and scope of practice, and recommended referral procedures. A new brochure under development by NC's representatives on the AAP's Committee on Psychosocial Aspects of Child and Family Health will facilitate this process.

6) Other Advocacy Efforts

The chapter joined with our colleagues in social work, psychology, and psychiatry for yet another failed effort to pass legislation requiring parity of MH benefits in insurance plans. Our chapter's resolution to address MH parity specifically in the AAP's Universal Health Insurance proposal was passed by the 2000 AAP Annual Chapter Forum. Our chapter's resolution to provide assistance to chapters on MH issues was adopted by the 2001 Annual Chapter Forum.

Private insurers lag well behind in improving MH benefits. The chapter formed a group, the Managed Care Solutions Committee, to move the chapter's advocacy efforts into the private sector. Medical directors of NC's major managed care organizations meet to discuss an agenda that is jointly developed by our chapter leadership and a health maintenance organization medical director, who is also a pediatrician. Modest first steps in relation to MH include an agreement to share behavioral health provider lists with pediatricians and attention-deficit/hyperactivity disorder coding guidelines specific to each of the plans.

Perhaps the Task Force's most long-lasting accomplishment will be the inclusion of pediatricians on state government committees and MH planning groups that previously did not include any primary care physicians.

NEXT STEPS

There is much left to do. Evaluation of NC's progress toward improving access to MH services for Medicaid-enrolled children will be a challenge. Medicaid has only claims data. In these data, MH services delivered by employed MH professionals under new "incident to" policies are so far indistinguishable from those delivered by their supervising physicians. On the other hand, we will be able to track the number and type of services delivered by newly enrolled independent providers and the total number of MH services delivered. Individual providers will be able to analyze their changes in reimbursement. Other measures will require a separate evaluation effort.

We remain hopeful that improvements in Medicaid will place pressure on private insurers if and when we achieve a buy-in option for children who are financially ineligible for Medicaid and SCHIP. If, as we suspect from experience in the SHP, improved MH benefits in Medicaid and SCHIP do not have adverse cost implications, there may be incentives for expanding private MH benefits, even without the buy-in option.

LESSONS LEARNED ABOUT WORKING WITH STATE GOVERNMENT

The following principles drawn from NC's experience may be helpful to pediatricians in their advocacy efforts:

1. Advocates must take advantage of political opportunities that present themselves. One such opportunity is a sympathetic person in a key government role; this might be a physician, a parent, or grandparent of a child with mental illness, or a child advocate. Full advantage is gained only if pediatricians with the requisite clinical expertise position themselves to be accessible and well-organized during this person's period of empowerment, with clearly articulated consensus positions on important policy areas.

2. State government administrators often view subspecialty care, especially that which is delivered at academic centers, as exotic and expensive. There may also be an adversarial relationship between the governmental agency and the medical center. Efforts by academic pediatricians to lobby state government on their own behalf appear self-serving and suffer from this baggage. Academic pediatricians will benefit from joining with community pediatricians in their AAP state chapter to approach Medicaid and other state agencies. The community pediatrician can speak to the value of subspecialty services in the care of their patients. This reframes the academicians' problems in terms of access to care for children in need, rather than survival of tertiary hospital infrastructure (a cause that few government officials will find appealing).

3. Personal relationships with state government leaders are at the heart of successful negotiations. These grow over time. Many AAP state chapters have developed these relationships over a long period, adding to their value as partners in any advocacy effort. Parents and grandparents of patients may also have relationships with administrators or with legislators, as well as passion and experience to bring to an advocacy effort.

4. State government leaders weary of listening to splinter perspectives of various advocacy groups. All advocates are best served by participating in a coalition, which agrees on a common agenda. If there are issues outside this common agenda--especially if they are in conflict with the common agenda--there should be advance understanding by all partners in the coalition. One partner's end run around a process and agenda developed by a coalition is very destructive to trust and credibility.

5. A government official will have little sympathy for enhancing physicians' income, especially because it probably far exceeds his own. The fundamental issue when seeking increased reimbursement should always be access. The AAP Members Only Channel provides links to a number of documents that make the case for the association between access and reimbursement (available at: .org/moc/).

6. Child advocates must seek out opportunities to understand the perspective of state government administrators and, when possible, to assist them with their problems. Frequently, these opportunities enable advocates to address their own concerns in an unexpected way. In the present economic environment, opportunities for cost-saving are particularly powerful. The state DMA will likely have a medical director--possibly a pediatrician--who is a good initial contact. By linking DMA to pediatricians with expertise in the management of complex and expensive conditions, advocates can assist Medicaid in reducing cost and improving quality, while laying the groundwork for a productive problem-solving relationship.

7. Child advocates must pursue strategies that are compatible with the political and economic environment. Administrators of state government agencies serve political leaders. They are looking for opportunities to align themselves with their constituents' interests.

8. Specific strategies most beneficial in negotiating with Medicaid will necessarily vary from state to state. The following section suggests some approaches that may yield results.

APPROACHES TO MEDICAID

The exact approach a state uses to negotiate with Medicaid will depend on the particular shortcomings of that Medicaid program. Examples might include the following:

* Codes reimbursed by Medicare but not Medicaid

* Absence of reimbursement for visits not resulting in a diagnostic code (ie, screening, testing, multivisit assessment)

* Absence of reimbursement for nonface-to-face services (telephone consultation, record review, parent or school conferences, etc)

* Restrictions built into the "incident to" policy (supervision requirements, failure to reimburse categories of MH professionals)

* Impediments to reimbursement for MH services delivered on school premises

* Failure to recognize advanced credentials of physicians (ie, no enhanced fee for a more complex service delivered by a more highly trained professional)

* Failure to reimburse categories of MH professionals and MH professionals in certain employment arrangements

* Monopolies of state MH programs

* Managed care policies excluding the primary care physician from referral/management decisions

* Monthly renewal of Medicaid eligibility (as opposed to yearly)

* Across-the-board inadequacies in reimbursement

The negotiation process involves exploring the feasibility of each of these strategies with Medicaid leaders. Some will have more appeal than others, depending on that Medicaid agency's history and political climate. Child advocates dealing with tight state budgets must fight the perception that increasing access will balloon costs. NC's experience with its SHP (see above) and the experience of other plans that provide MH parity (6) contradict this perception: total expenditures for MH care have, at most, modestly increased with parity; furthermore, plans with parity have experienced the very positive outcome of decreased inpatient days. There are undoubtedly other needed MH care reforms, such as those that build the capacity of neglected systems, that will be financially costly; advocates for these changes must build their case around the human and economic costs of untreated behavioral problems.

TABLE 1. Excerpt from the NC Pediatric Society Position Paper

 Medicaid to Private Private
 Pediatrician Plan 1 Plan 2
 in Private
 Practice

Current Procedural $ $ $
 Terminology
 Code 99205,
 comprehensive,
 new patient

The pediatrician spent 120 minutes evaluating a hyperkinetic 7-year
old, implementing and coordinating therapy for attention-deficit/
hyperactivity disorder, writing reports, and following up by
telephone. If this had been an established patient instead of a
new patient, the Medicaid reimbursement would have been lower
still.

(a) We anticipate that the steps in bold print will facilitate pediatricians' collegial relationships with, employment of, and/or co-location with MH professionals. We believe that these changes will, in turn, improve access to MH services for Medicaid-enrolled children and increase the likelihood that these services will be provided within or coordinated with a child's medical home.

(b) "Incident to" rules govern billing for services delivered by a physician's employee in the name of the physician. Before August 2000, NC's rules restricted "incident to" billing to PhD psychologists. Before September 2000, NC's rules required the physician to be on-site at the time the employee delivered the service.

REFERENCES

(1.) Comprehensive Child Health Plan: 2000-2005. Report to the North Carolina Department of Health and Human Services. Chapel Hill, NC: North Carolina Institute of Medicine; May 23, 2000:86

(2.) Burns BJ, Costello EJ, Angold A, et al. Children's mental health service use across service sectors. Health Aff. 1995;14:147-159

(3.) Comprehensive Child Health Plan: 2000-2005. Report to the North Carolina Department of Health and Human Services. Chapel Hill, NC: North Carolina Institute of Medicine; May 23, 2000:77

(4.) Data on the Mental Health Benefit. Prepared by the North Carolina Psychological Association from data supplied by the North Carolina State Health Plan Office. April 1999

(5.) Sturm R. How expensive is unlimited mental health coverage under managed care? JAMA. 1997;278:1533-1537

(6.) A new health benefit. NC Medicaid Bulletin. June 2000:13

(7.) Referral policy for specialty care. NC Medicaid Bulletin. August 2001:4

(8.) Incident to policy for licensed clinical social workers and clinical nurse specialists. NC Medicaid Bulletin. August 2000:14

(9.) Supervision of services performed in health departments. NC Medicaid Bulletin September 2000:21

(10.) Independent mental health provider seminars. NC Medicaid Bulletin. January 2001:46

(11.) Outpatient mental health services for children birth through 20 years of age. NC Medicaid Bulletin. February 2001:2

(12.) Credentialing requirements--correction to terminology in January 2001 Medicaid special bulletin I, provider enrollment guidelines. NC Medicaid Bulletin. March 2001:18

(13.) Place of service for outpatient therapy. NC Medicaid Bulletin. September 2001:11

Jane Meschan Foy, MD *; Marian F. Earls, MD ([double dagger]):; and David A. Horowitz, MD [section]

From the * Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, North Carolina; ([double dagger]) UNC-Chapel Hill, the Moses H. Cone Memorial Hospital Pediatric Teaching Program and Guilford Child Health, Greensboro, North Carolina; and [section] UNC-Chapel Hill, Triangle Pediatric Center, Cary, North Carolina.

Received for publication Jan 29, 2002; accepted Jun 12, 2002.

Address correspondence to Jane Meschan Foy, MD, Department of Pediatrics, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail: